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�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO <br /> ArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 .416 8/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - - <br /> (Complete In Triplicate) <br /> Application is hereby made `to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �. �• tv. C"�US TRACT <br /> Owner's Name V <br /> Phone. 36 r- 0 3 YJ <br /> Addressa, City ` <br /> n -, .... <br /> r Contractor's Name License #/Co 23 72 Phone 6 :a,?,4 <br /> " TYPE OF WORK (Checkj-" NEW-WELL`-/ DEEPEN /7 RECONDITION,'/_7�' DESTRUCTION- 1-7- - ' <br /> PUMP INSTALLATION REPAIR PUMP REPLACEMENT /7 <br /> Other /_7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL `1 <br /> INTENDED USE TYPE OF WELL t'-CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool-. .-_ Dia. of.. Well Excavation <br /> Domestic/private ' ; _..DrilIed.__ .-Dia.hof Well--Casing <br /> Domestic/public Driven ,Gauge of Casing <br /> -_Irrigation Gravel Pack Depth of Grout Seal <br /> —Cathodic ProtectionRotary Type of Grout' � <br /> Disposal T� ... <, Other Other Information <br /> Geophysical—__ ___ ___._ __ � Surface Seal Installed B <br /> PUMP INSTALLATION.- Contractor { <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP,:REPAIR: / State Work Done <br /> 2EES1_RUCTI0N OF WELL: Well Diameter t Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San, Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.. The above <br /> information is true to the best•of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIM AND A F AL INSP ION. i <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE U <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ,BY DATE '~ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITT FINAL INSPECTION <br /> INSPECTION BY 61'?- DATE d'z,3 r INSPECTION BY DATE // <br /> 4 E H 1426 Rev. 1-74 1--74 2M <br />